Studies have shown that elderly patients with one of six major chronic diseases create the highest costs for Medicare and private health insurance companies from hospital admissions and readmissions. The major contributing factor for this out-of-control spending is the lack of community or ambulatory care coordination. Once patients with chronic diseases are discharged from hospitals, they enter a fragmented and reactive clinical model that does neither engage nor support them throughout the continuum of care. This fragmented system keeps patients and healthcare providers disconnected and out of sync, creating confusion for patients and misinformation and inefficiency for healthcare providers. Patients with chronic diseases are often left unattended, uninformed and in total disconnect from community care. Typically, due to time restraints, declining reimbursements, and lack of resources, the healthcare system waits until the patient reaches a critical point and use the ER as patient's re-entry into the health care system.